tbuckley/cabot-search huggingface dataset:
BT24 Use of specialist advice and guidance for dermatology services: the importance of high-quality images in reducing double activity
Authors: Julia Schofield, Krisztina Scharrer
Journal: British Journal of Dermatology (2023)

Abstract The use of specialist advice and guidance (A&amp;G), where primary care healthcare professionals request diagnostic and management advice from specialists, is advocated as the ‘front door’ to dermatology services, to optimize referral management. This approach provides the opportunity for a two-way interchange between primary and specialist services, and can facilitate triage to appropriate dermatology services in a timely fashion. For A&amp;G to work effectively, the expectation is that images will accompany the A&amp;G interaction. Ideally, dermoscopic images would accompany skin lesion A&amp;G requests. It is important that the images are of a high enough quality to enable the reviewing clinician to provide a diagnosis and management plan so that ‘double activity’, where an A&amp;G request is reviewed and the patient needs to be seen because of poor-quality images, is avoided. We introduced specialist A&amp;G in August 2021 and developed referral forms for skin lesions. Dermatoscopes were provided to practices. The aim of this study was to review the quality of skin lesion A&amp;G requests and, in particular, to identify whether a diagnosis and management plan was possible based on the information and images provided. Consecutive skin lesion A&amp;G requests were reviewed over a 4-week period, and information was collected on the images accompanying the request and whether the reviewing clinician was able to make a diagnosis and management plan. In total, 160 skin lesion A&amp;G requests were reviewed over the 4-week period. A skin lesion referral form accompanied 42% of the requests, and 92% were accompanied by macroscopic images (42% clearly labelled) and 59.5% by dermoscopic images. In 32% of the requests, it was not possible to make a diagnosis and management plan. This study highlights the fact that the quality of images accompanying A&amp;G skin lesion referrals is often not good enough to make a diagnosis and management plan. Many of these patients will therefore need to be seen for a face-to-face appointment, which leads to ‘double activity’. If A&amp;G services are to work effectively, then it is essential that high-quality images, ideally including dermoscopy images for skin lesions, accompany the A&amp;G requests. Systems need to identify appropriate models to support image-taking services. Such models can be developed locally and might include community image-taking hubs based in agreed primary care settings or community diagnostic centres. A suitably trained workforce needs to be developed to take and send the images.
PA17 Paediatric-onset mastocytosis: a retrospective review
Authors: Siwaporn Hiranput, Kasthuri Nallathamby, Lucy Smith, Paul Devakar Yesudian
Journal: British Journal of Dermatology (2023)

Abstract Mastocytosis is characterized by an abnormal accumulation of mast cells in different organs. The skin is the most frequently affected site. Most cases of paediatric-onset mastocytosis are benign, localized to the skin and regress spontaneously. We retrospectively reviewed the case notes of paediatric patients with a diagnosis of mastocytosis in dermatology departments within our region between 2021 and 2022. Seventeen patients were identified. The disease was more prevalent in males (male-to-female ratio 1.8s : 1). The median age at onset was &amp;lt; 1 year (range birth–4 years). The lesions were described as solitary (n = 9), macular (n = 6) and maculopapular (n = 2). The torso was involved in 16 patients. Other body sites affected were the face (n = 2), scalp (n = 1), limbs (n = 5) and buttock (n = 2). Most patients were asymptomatic (n = 12). Symptoms, including abdominal pain (n = 3), pruritus (n = 2), musculoskeletal pain (n = 1), diarrhoea (n = 1), flushing (n = 1), headache (n = 1) and dizziness (n = 1), were reported. Darier sign was positive in 11 patients and negative in three (not documented in three). None of the patients had bone marrow examination. One patient underwent a skin biopsy, which confirmed mastocytosis in the skin; the remaining 16 patients were diagnosed with cutaneous mastocytosis based on the characteristic clinical features. The disease was classified into mastocytoma (n = 8) and urticaria pigmentosa (n = 9). Five patients with urticaria pigmentosa were assessed for lymphadenopathy and organomegaly: four had blood investigations, including serum tryptase (n = 4), full blood count (n = 2) and liver function tests (n = 2); one had an abdominal ultrasound. No abnormality was found. Patients with mastocytoma were not examined for lymphadenopathy or organomegaly, or had further investigations for systemic involvement. Eight patients were managed by watchful monitoring. Nine patients received active treatments, including topical steroids (n = 6), antihistamines (n = 6), oral sodium cromoglicate (n = 1), phototherapy (n = 1), epinephrine autoinjector (n = 1) and cosmetic camouflage (n = 1). Partial regression was observed in seven cases at a median follow-up of 3 years (range 1–14), and seven had persistent disease. Six patients remain under long-term follow-up, and eight were discharged with a median follow-up period of 1.5 years (range 1–14). Five patients were followed to adolescence (disease was persistent in three cases and there was partial regression in two cases; none had complete resolution). While serum tryptase levels do not appear to have a prognostic value in the paediatric population, we would recommend checking these in patients whose disease persists beyond adolescence as this may indicate progression to systemic mastocytosis.
P16 Cutaneous renal cell carcinoma metastasis with scrofuloderma as the initial presentation of metastatic renal cell carcinoma: a diagnostic challenge
Authors: Rohit Kothari
Journal: British Journal of Dermatology (2023)

Abstract Renal cell carcinoma (RCC) with cutaneous metastasis is uncommon and accounts for approximately 3–5% of metastatic RCC, with an unfavourable prognosis. We present an unusual and difficult case of advanced RCC presenting initially with cutaneous metastasis and scrofuloderma, with identical morphology of the lesions. It also highlights the importance of dermatologists in the early diagnosis and management of such cases. A 50-year-old man presented with gradually progressive, multiple erythematous discharging nodules over the right side of his neck of 3 months’ duration. He described a weight loss of 10 kg, intermittent undocumented fever with headache and two episodes of uninvestigated transient haematuria in the last 6 months. He had received multiple courses of antibiotics without any relief. A skin biopsy and immunohistochemistry confirmed cutaneous RCC metastasis with a primary advanced metastatic left RCC, involving the brain as well. A total left nephrectomy was done and he was started on lenvatinib, everolimus and radiotherapy, following which there was suboptimal response and he started developing similar nodular lesions over the left axilla and chest wall, and a puckered crusted plaque over the left lateral abdomen 1 week post treatment. Follow-up at 8 weeks revealed a significant response in the neck lesions; however, the new lesions on the left side did not respond, following which a dermatology consultation was sought again. A skin biopsy from the new lesions confirmed scrofuloderma. Tissue polymerase chain reaction and culture were positive for mycobacterium tuberculosis. He was diagnosed as having scrofuloderma and started on daily isoniazid, rifampicin, ethambutol and pyrazinamide for 2 months followed by daily isoniazid and rifampicin for 4 months. Follow-up at 6 months revealed well-healed lesions, and the systemic symptoms and discharge had abated. The cutaneous metastatic lesions had also healed completely. Here, we present an interesting case of cutaneous RCC metastasis with coexisting scrofuloderma as the initial manifestation of an advanced RCC, posing a diagnostic challenge due to similar morphology. On this background, a recurrence of cutaneous metastasis was the first possibility considered for the new skin lesions. The delay in diagnosis led to significant morbidity in our patient, emphasizing the role of early dermatology consultation in the management of such cases. A high index of suspicion for conditions masquerading as cutaneous metastasis, as well as a lower threshold for skin biopsy, may improve the prognosis dramatically.
DS03 Lentigo maligna: is it time to put down the scalpel?
Authors: Navreet Paul, Kami Lecamwasam, May Fadhil, Jennifer Garioch
Journal: British Journal of Dermatology (2023)

Abstract Lentigo maligna (LM) is a subtype of melanoma in situ that often proves to be a diagnostic and therapeutic challenge. Treatment aims to prevent progression to an invasive tumour called lentigo maligna melanoma (LMM). In the UK, common treatment modalities include conventional excision, staged re-excisions, slow Mohs surgery or expectant monitoring. Although considered the ‘gold standard’, surgical excision of LM can be disfiguring as it frequently affects cosmetically sensitive areas requiring complex surgical reconstructions. Topical imiquimod 5% presents a pragmatic alternative treatment modality without the need for surgery. In vivo reflectance confocal microscopy (RCM) allows real-time noninvasive delineation of LM. Evidence suggests this is an effective diagnostic tool for pre- and post-treatment evaluation (Brand FL, Jafari SM, Hunger RE. Confocal microscopy and lentigo maligna: an in vivo pilot study for the assessment of response to imiquimod therapy. Dermatology 2019; 235:150–5). We retrospectively analysed 35 cases of histologically confirmed LM that completed treatment with imiquimod between 2018 and 2022. The average patient age at diagnosis was 73.9 years, with a female : male ratio of 18 : 17. Following assessment with RCM, patients were prescribed a protocol of topical imiquimod 5% once a day, 5 days per week for 12 weeks, along with instructions to apply this 10 mm beyond the mapped area or a cosmetic unit (Australia and New Zealand Melanoma Trials Group RADICAL trial). Patients were counselled about expected side-effects; all completed the course and achieved significant inflammation and superficial ulceration. To ensure a response was achieved, the following stepwise interventions were used: application increased to 7 days per week, occlusion with a dressing and addition of a topical retinoid. Repeat RCM was performed 6 months after treatment completion. At this point, 30 of 35 (86%) patients responded with no evidence of residual LM on RCM. Three cases required a second course of treatment. Two of these were shown to be clear on RCM, while the third is clinically clear and awaiting RCM confirmation. A fourth patient was lost to follow-up. A further patient has failed two courses and is about to embark on a third round of treatment. In total, 16 cases completed the 12-month review and maintained clearance. We demonstrate that imiquimod is an effective treatment for LM, potentially avoiding extensive surgery and complex reconstruction. Reflectance confocal microscopy can be used to delineate the extent of the LM and assess the post-treatment response. Our preliminary data suggest a significant proportion of LM cases achieved clearance with no recurrences to date. Follow-up of these patients will help evaluate the long-term efficacy of imiquimod, but our data suggest this treatment protocol provides a promising alternative to surgical intervention.
BH07 The socioeconomic burden of alopecia areata
Authors: Kerry Montgomery, Fabio Zucchelli, Julie Clayton, Andrew Messenger, Matthew Harries
Journal: British Journal of Dermatology (2023)

Abstract It is widely acknowledged that alopecia areata (AA) can have a significant impact on psychosocial wellbeing and daily functioning. Individuals with AA often seek treatments or products to promote hair regrowth or use strategies to conceal their hair loss, which results in a financial cost to the individual. The current study aimed to examine the socioeconomic burden of AA, to understand the wider impact of the condition. A total of 829 UK-based participants completed an online survey. Demographic and condition-specific data were collected, alongside spending on AA-related products and services over the preceding year, and AA-associated work absenteeism and presenteeism. Participants predominantly identified as female (85.9%) and White (92.7%), with a mean age of 42.7 years and median duration of AA of 10.94 years. The median expense on AA-related products and services over the preceding year was £840. Wigs incurred the greatest cost to individuals (median £700). Although accessed by approximately 10% of participants, private dermatology and mental health services also incurred significant costs, when used. Over half of the sample also reported that the products and services they used made their quality of life a little or much better. Using hierarchical regression analysis, sex and AA symptoms uniquely predicted higher financial burden, with females and those with more severe AA spending a greater proportion of their disposable income on AA-related products and services. Lower disposable income also predicted greater financial burden from spending. Regarding work absenteeism, 21% of participants reported being signed off work due to AA since their diagnosis, and over the preceding 7 days, 10.5% of those in employment (n = 525) reported missing &amp;gt; 1 h of work due to AA. Of 154 participants claiming work-related benefits, 33 said their reason for claiming was connected to their AA. The presenteeism findings suggest, on average, a minimal effect of AA on participants’ work productivity in the preceding 7 days, with those more recently diagnosed reporting lower productivity. The findings suggest that products/services to manage the aesthetic consequences of hair loss from AA are costly yet broadly valued by individuals. It is concerning that those with lower disposable income spent proportionately more on AA products and services, implying these individuals consider this spending as essential. The other risk factors identified in the findings also require consideration by health providers, commissioners and policymakers when designing services to support the wellbeing of people living with AA. Funding: this study was funded by Pfizer Inc.
BH08 A clinical case of retronychia, a rarely described post-traumatic proximal ingrown nailplate: a condition of the ‘nail’
Authors: Charles Cathcart, Sarah Walker-Date, Avinash Belgi, Prashanthi Jeyakanth
Journal: British Journal of Dermatology (2023)

Abstract Retronychia is a recently described inflammatory disorder that leads to proximal ingrowth of the nail and paronychia. There are fewer than 100 published cases of retronychia, leading to a poor understanding of the disorder and a delay in diagnosis and treatment. Increased understanding for clinicians will be critical in avoiding misdiagnosis and effective management (Costa TPE. Retronychia: a paradigm shift? Skin Appendage Disord 2020; 6:268–71). A 36-year-old woman presented to dermatology with a near three-decade history of treatment-resistant painful, thickened yellow nails of both greater toes. Past medical history included bilateral bunions since the age of 14 years, which were surgically corrected. In the community, she had undergone partial nail avulsion by chiropodists. Subsequently, she received multiple courses of antifungal lacquer and oral terbinafine, all with no effect, and continued regrowth of abnormal thickened nails. On examination of her greater toes, the proximal nailfolds lacked cuticles. The nails showed horizontal ridges, were thickened by stacking of nailplates and had a yellow discoloration. Investigations for fungal nail were negative. A clinical diagnosis of retronychia was made. Retronychia was first recognized in 1999 and is a combination of nailplate ingrowth into the proximal nailfold and the generation of multiple misaligned proximal nailplate lamellae. It is more common in women, typically affects the great toes and is triggered by repetitive microtrauma related to sports, inadequate footwear or, in this case, bunions (de Berker D, Richert B, Duchard E et al. Retronychia: proximal ingrowing of the nail plate. J Am Acad Dermatol 2008; 58:978–83). As in this case, most patients are inadequately treated with antifungals and antibiotics, perhaps due to signs of paronychia resulting in treatment failure and significant psychological impact. If cases are recognized early, conservative management with topical steroids applied to the proximal nailfold is effective. In advance cases, as with this patient, surgical nailplate avulsion with nail matrix ablation is the only curative management. Awareness of the clinical signs would be a valuable learning point for clinicians.
BH03 Lipoedematous scalp occurring in two female siblings: further evidence of a genetic role?
Authors: Nada Khalil, Carolina Fernandez, Neil P Patel
Journal: British Journal of Dermatology (2023)

Abstract Lipoedematous scalp (LS) is a rare disorder characterized by thickening of the adipose subcutaneous scalp layer. We describe an unusual case of two female siblings presenting with the same condition. A 58-year-old black Caribbean woman presented with a 7-year history of an itchy, painful and scaly scalp, without any associated hair loss. Mycology had been negative. There was a history of paranoid schizophrenia and bipolar disorder, for which she was taking olanzapine. Body mass index (BMI) was 39 mg kg–2. Examination revealed a thickened scalp with a spongy consistency, with no associated surface change or hair loss. Scalp ultrasound was performed, demonstrating a scalp thickness of 12 mm at the vertex (normal range 5–6 mm). Scalp biopsy revealed prominent fat in the dermis around the hair follicles, with follicular distortion and some focal perifollicular fibrosis. Based on these findings, a clinicopathological diagnosis of LS was made. The patient’s 63-year-old sister presented with similar scalp symptoms. She had a background of diabetes mellitus type 2, migraine and hypomania and was taking metformin, gliclazide, atorvastatin, sodium valproate and mirabegron; her BMI was 26 mg kg–2. Scalp ultrasound revealed diffuse thickening of the subcutaneous fat measuring 9 mm at the vertex, which was also consistent with a diagnosis of LS. The pathogenesis of LS is poorly understood. It is more common in females, and there appears to be an association between LS and obesity (Yasar S, Gunes P, Serdar ZA, Tosun I. Clinical and pathological features of 31 cases of lipedematous scalp and lipedematous alopecia. Eur J Dermatol 2011; 21:520–8). Studies have implicated leptin, a hormone that regulates distribution of adipose tissue. There is limited evidence for a genetic role in LS. We identified three female cases of LS in the literature with a positive family history in their daughters (Yasar et al.) but no cases of siblings with LS. We identified one reported case of the related disorder, lipoedematous alopecia, occurring in a pair of female siblings (Koç Yıldırım S, İğde B. Lipedematous alopecia: report of two female siblings. J Cosmet Dermatol 2022; 21:1324–5). Our case highlights a possible genetic role in the pathogenesis of LS, and further studies are needed to investigate this link further.
DS04 Clinical outcomes of the management of basal cell carcinomas in individuals aged 90 years and over
Authors: Isabelle Nicholls, Marc Moncrieff, Martyn Patel, Jenny Nobes, Jennifer Garioch
Journal: British Journal of Dermatology (2023)

Abstract This retrospective cohort study examined our practice for the management of basal cell carcinoma (BCC) in the very elderly, to identify subgroups where intervention could be minimized, based on frailty and trends in survival. All patients aged ≥ 90 years with histologically confirmed BCC during 2017 and 2018 were included within the study (n = 319). Data on lesion characteristics (size, location and subtype), presence or absence of symptoms, patient characteristics (age, comorbidities, frailty score, anticoagulant use and presence of pacemaker) and treatment choice (surgery, radiotherapy, topical, systemic or observation) were collected. Overall survival was the primary endpoint. Age was the most significant predictor of survival [hazard ratio (HR) 1.10, 95% confidence interval (CI) 1.04–1.17; P = 0.001] with a maximum threshold analysis identifying 93 years as the significant age cutoff point. Median survival was 40 months for those aged ≤ 93 years and 28 months for those aged &amp;gt; 93 years (P = 0.002). Patients with dementia had a worse survival than those without [median survival 25 months vs. 35 months (HR 1.92, 95% CI 1.18–3.13); P = 0.009]. None of the 23 individuals with a diagnosis of dementia was alive at 5 years. There was a statistically significant difference in survival for patients who received treatment for their BCC (n = 294) compared with those observed [n = 25; median survival 34 months vs. 21 months (HR 0.54, 95% CI 0.34–0.85); P = 0.007]. There was no difference in survival in individuals with a history of cancer, cardiac or cerebrovascular disease or immunocompromise, compared with those without. Similarly, the use of anticoagulants or presence of pacemaker did not affect survival. Basal cell carcinoma subtype (nodular, infiltrative) did not impact outcomes either, although the difference between lesion size (&amp;lt; 10 mm, ≥ 10 mm) was approaching statistical significance (HR 1.36, 95% CI 0.98–1.87; P = 0.062). No patients required Mohs surgery in the study period. Factors that appeared to influence the preference for primary radiotherapy over surgery were the concurrent use of anticoagulants (P = 0.05) and site of lesion (P = 0.04). All 25 of the lesions treated with radiotherapy were on the head and neck. This study provides evidence in support of the active treatment of BCC in individuals aged ≥ 90 years seen in secondary care. Being fit enough to attend hospital appointments could be seen as a self-selecting process. Conservative options may be preferable in patients with dementia or those &amp;gt; 93 years old. While survival in this cohort is good, accurate assessment of patient frailty is key for selecting those individuals with a poor prognosis to ensure they are not referred for unnecessary intervention.